Basic Information
| Provider Information | |||||||||
| NPI: | 1063763282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
| FaxNumber: | 2607283808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 MERCER AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467332303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607242145 | ||||||||
| FaxNumber: | 2607283808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 28091111A | IN | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.